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The trade-offs in field trauma triage: A multiregion assessment of accuracy metrics and volume shifts associated with different triage strategies

Newgard, Craig D. MD, MPH; Hsia, Renee Y. MD, MSc; Mann, Clay N. PhD, MS; Schmidt, Terri MD, MS; Sahni, Ritu MD, MPH; Bulger, Eileen M. MD; Wang, Ewen N. MD; Holmes, James F. MD, MPH; Fleischman, Ross MD, MCR; Zive, Dana MPH; Staudenmayer, Kristan MD; Haukoos, Jason S. MD, MSc; Kuppermann, Nathan MD, MPHthe Western Emergency Services Translational Research Network (WESTRN) Investigators

Journal of Trauma and Acute Care Surgery: May 2013 - Volume 74 - Issue 5 - p 1298–1306
Original Articles

BACKGROUND: National benchmarks for trauma triage sensitivity (>=95%) and specificity (>=50%) have not been rigorously evaluated across broad populations of injured patients. We evaluated the impact of different field triage schemes for identifying seriously injured patients across a range of sensitivity values. Impact metrics included specificity and number of undertriaged and overtriaged patients compared with current triage practices.

METHODS: This was a retrospective cohort study of injured children and adults transported by 48 emergency medical service (EMS) agencies to 105 hospitals in 6 regions of the Western United States from 2006 through 2008. Hospital outcomes were probabilistically linked to EMS records through trauma registries, state discharge databases, and state emergency department databases. The primary outcome was an Injury Severity Score (ISS) of 16 or greater. We evaluated 40 field predictor variables, including 31 current field triage criteria, using classification and regression tree analysis and cross-validation to generate estimates for sensitivity and specificity.

RESULTS: A total of 89,261 injured patients were evaluated and transported by EMS providers during the 3-year period, of whom 5,711 (6.4%) had ISS of 16 or greater. As the 95% sensitivity target for triage was approached (from the current value of 87.5%), decision tree complexity increased, specificity decreased (from 62.8% to 18.7%), and the number of triage-positive patients without serious injury doubled (67,927 vs. 31,104). Analyses restricted to children and older adults were similar. The most consistent modification to the current triage algorithm to increase sensitivity without a major decrease in specificity was altering the Glasgow Coma Scale (GCS) score cutoff point from 13 or less to 14 or less (sensitivity increase to 90.4%).

CONCLUSION: Reaching the field triage sensitivity benchmark of 95% would require a large decrease in specificity (increase in overtriage). A 90% sensitivity target seems more realistic and may be obtainable by modest changes to the current triage algorithm.

LEVEL OF EVIDENCE: Diagnostic test, level II.

From the Center for Policy and Research in Emergency Medicine (C.D.N., T.S., R.S., R.F., D.Z.), Department of Emergency Medicine, Oregon Health and Science University, Portland; Clackamas County American Medical Response (T.S.), Clackamas; and Lake Oswego Fire Department (R.S.), Lake Oswego, Oregon; Department of Emergency Medicine (R.Y.H.), University of California San Francisco, San Francisco General Hospital, San Francisco; Departments of Emergency Medicine (N.E.W.) and Surgery (K.S.), Stanford University, Palo Alto; and Department of Emergency Medicine (J.F.H., N.K.), University of California at Davis, Sacramento, California; Intermountain Injury Control Research Center (N.C.M.), University of Utah, Salt Lake City, Utah; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington; Department of Emergency Medicine (J.S.H.), Denver Health Medical Center, Denver; and Department of Epidemiology, Colorado School of Public Health, University of Colorado School of Medicine, Aurora, Colorado.

Submitted: November 27, 2012, Revised: January 8, 2013, Accepted: January 8, 2013.

Abstract of these results were presented at the Resuscitation Science Symposium/American Heart Association meeting, November 14, 2010, in Chicago, Illinois.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (

Address for reprints: Craig D. Newgard, MD, MPH, Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, mail code CR-114, Portland, OR 97239-3098; email:

© 2013 Lippincott Williams & Wilkins, Inc.